SAF System presentation - July 2014

1Dr. Alon Amit Minimally Invasive Endodontics
Minimally Invasive
EndodonticsDr. Alon Amit July 2014

Comfort Zone

The mind is like a parachute –
It works better when it’s open

Let’s start with a short question

Rate the following factors according to their importance
when choosing an endodontic file system:
1. Preserves more sound dentin
2. Easy to use
3. Low chance for file separation
4. Cheap price
5. Reduces treatment time
6. Provides better cleaning
Let’s start with a short question

What are we going to discuss today?
Requirements of RCT Current technologies New technology

Healing
The “Holy Trinity” of Endodontics
&
Cleaning: The removal of tissue remnants
harboring bacteria and preventing proper seal
Shaping: The removal of infected Inner layer of dentin
to facilitate effective irrigation and obturation
Disinfection: The use of irrigants
to remove biofilm from the canal
Obturation: Preventing re-infection
of the clean root canals

Root Canal Treatment success rate
Absence of Apical Periodontitis as seen in X-ray photos
• Orstavik 1996 Int J Endod 29:150-155 85%
• Hoskinson et al 2002, OOOOE 93: 705-715 74%
• Orstavik et al 2004, Europ J Oral Science 112: 224-230
79%
• Kojima et al 2004, OOOOE 97:95-9 79%-83%
• de Chevinggy et al 2008, J Endod 34: 258-263 82%
• Siqueira et al 2008, OOOOE 106: 757-762 76%
By Specialists:
~80%
• De moor (Belgium) 2000 Int J Endod 33: 113-120 40%
• Dugas, Friedman (Canada) 2003 Int J Endod 36: 181-192
49%-56%
• Jimenez-Pinzon (Spain) 2004, Int J Endod 37: 167-173
36%
• Tsuneishi (Japan) 2005, OOOOE 100(5): 631-5 60%
• Georgopoulou (Greece) 2005, Int J Endod 38: 105-111
40%
• Kirkevanget (Denmark) 2006, Int J Endod 39: 100-107
40%
In general:
~50%

Root CanalAnatomy on 2D X-ray

Dentists tend to relate to all root canals as if they had a
uniform round cross section
The Common Misconception

Complex Anatomy
µ-CT courtesy of Prof. Frank Paqué

µ-CT by Prof. Marco Versiani

Tooth Anatomy

Oval cross section:
mandibular incisors
canines
premolars
distal roots of mandibular molars
“Tear-shaped” cross section:
premolars
mesial roots of mandibular molars
mesio-buccal roots of maxillary molars
“Long-oval–shaped canals are relatively common, with a
prevalence of about 25% in the apical third of human
teeth ...In some teeth the prevalence may be greater than
50%”
Wu & Wesselink Oral Med Oral Pathol Oral Radiol Endod 2000;
89:739-43

And in reality…
Dr.Amir Weissman (Israel)

Combined with ComplexWall Surface
SEM (Scanning Electron Microscopy) data

Inexpensive, has a track record,
usually safe, but…
• Time consuming
• Inflexible - difficulty
negotiating curved canals
• Extrude debris periapically
• Pack debris into recesses
• Sequential irrigation
Traditional Technology
Stainless-Steel Hand Files

Advanced technology, a game-changer
in modern endodontics:
• Motorized instrumentation
• Faster preparation
• Able to negotiate curved canals
However…
CurrentTechnology
Rotary Files

Evolution of Rotary NiTi Files
• Profile 1993
• Quantec 1996
• GT 1998
• Hero642 1999
• FlexMaster 2000
1st Generation
Symmetrical Flutes
&
UniformTaper
• Race 1999
• ProTaper 2001
• K3 2001
• Hero Shaper 2002
• Revo-S 2009
2nd Generation
Asymmetrical Flutes
and/or
Non-UniformTaper
• GT – X (M-wire) 2009
•TF (R-phase) 2009
• ProTaper Next 2013
3rd Generation
Innovative Metallurgy

• Reciproc 2011
• WaveOne 2011
4th Generation
Same design,
Reciprocation
• BFR 2014
•TRUshape 2015
5th Generation
Innovative Metallurgy,
Curved
Rotating Blade with Flutes

Peer-reviewed research has shown, so far, the following consequences:
• Unpredictable File separation – even with advanced metallurgy and reciprocation
reciprocation
• Excessive removal of dentin – especially with high-taper systems
• Periapical debris extrusion – especially with reciprocation
• Packing of debris into recesses
• Efficiency of NaOCl is reduced when used with single-file systems, due to shorter
to shorter working time and non-sequential work
• Formation of dentinal Micro-cracks, especially with single-file systems
Issues with Rotary NiTi Files

1st Generation 4th Generation
Profile 1993 WaveOne 2011
This represents 20
years of NiTi rotary
files evolution!

Rotating Blade with Flutes =
A Machining Device

Ignoring
the
3D shape
of the root canals
!
Common to all

Cone beam CT presenting oval cross-sections of canals

Efficacy of rotary instruments with greater taper in
preparing oval root canals
A. El-Ayouti et al, Int Endod J 2008; 41(12):1088-92
“No instrumentation technique was able to circumferentially prepare the oval outline of root
canals.
Nevertheless, instruments with greater taper (ProTaper and Mtwo) were more efficient than NiTi
hand-files, but this was, in some cases, at the expense of remaining dentine-wall thickness.”
* All instruments were used in Brushing/ Circumferential filing

2 mm 4 mm 6 mm
Yellow - After preparationRed - Before preparation
Rotary File – µCT Analysis
Metzger et al, J Endod 2010; 36(4):679-90

All root canals
are machined to a
round cross-section

Rotary File – Excessive enlargement
Excessive enlargement: To include all canal surface
To allow effective irrigation
To shape for industrial master cones

Rotary File – Excessive enlargement
* - would make a great 2D X-ray
*
SAF
Rotary

Peters & Paqué, Int Endod J 2003; 36(2):86-92
Red - Over 40% of the surface is untouched by the file
Green - Affected surface ; Clear - Final preparation
Before After Superposition
µCT Analysis - Root Canal Transportation

Percentage of Untreated Root Canal Surface
Paqué et al J Endod 2009; 35:1056-9
µCT Analysis - Maxillary Molars
Paqué et al 2009
ProFile
ProTaper
Flexmaster
Lightspeed
GT
NiTiKFile
Can
we do
Better?

Paqué et al. J Endod 2010; 36:703–707
Distal canal (n= 12)*
Whole canal Apical third
Hedström 73.3% 74.7%
ProTaper - as 1 canal 79.9% 65.2%
ProTaper - as 2 canals 59.6% 65.2%
Percentage of Untreated Root Canal
Surface
(long-oval
canals)
µCT Analysis - Distal roots of mandibular
molars
Can we do better ?

Paqué et al. J Endod 2009; 35:1044-1047
Before After Packed Debris
µCT Analysis - Hard Tissue Debris
Accumulation

Packing of Debris During Rotary Instrumentation

Dr. Clifford Ruddle
Packing of Debris During Rotary
Instrumentation

Can conventional irrigation really clean?
“The notion that “the file shapes; the irrigant cleans” represents wishful thinking
rather than a scientifically based fact, at least in flat-oval root canals”
De Deus et al., J Endod 2011; 37:701-705

De Deus et al., Int Endod J, 2008; 34:1401–1405
“key- hole”
appearance
of
preparation

Irrigation - “vapor-lock” effect
Excessive pressure =
NaOCl accident

Packing of Debris
Dr. AmirWeissman (Israel)
“50.8% of the packed dentin debris could not be removed even
with EDTA irrigation and PUI (passive ultrasonic irrigation)”
Paqué, Boessler & Zehnder, Int Endod J, 2011; 44(2):148-53

Onnick et al., J Endod 1994; 20:32-7
Incomplete root fractures in the history of endodontic
research
Turek et al., J Endod 1982; 8:437-43
Association with excessive removal of
dentin:
Association with obturation
techniques:

Shemesh et al. J Endod 2011; 37: 63-
Iatrogenic Micro-Cracks & Craze
Line Formation During Rotary
Instrumentation

Kim et al. J Endod 2010; 36(7):1195-9
Stress generation by rotary files and its
relation to micro-cracks
The stiffer file designs
generated higher stress
concentrations in the apical
root dentin during shaping
of the curved canal, which
raises the risk of dentinal
defects that may lead to
apical root cracking

Minimally Invasive Endodontics
Paradigm Shift
In Root CanalTreatment

Achieve minimally-invasive
3D root canal shaping, cleaning
and simultaneous Irrigation.

Abrasive Surface

The hollow design enables the SAF to be elastically compressed along its cross section (A)
when inserted into a canal previously negotiated with a no. 20 K-file (B)
Compression

Attempting to expand, the SAF applies light continuous pressure
along the entire circumference of the root canal wall
Gradual Expansion

Compressibility
0
2
4
6
8
10
12
14
16
18
20
0.15 0.25 0.35 0.45 0.55 0.65 0.75 0.85
Diameter (mm)
DistancefromTip(mm)
1.5 mm
0.450.20

Adaptation to oval cross-sections
2.4 mm
0.2 mm
1.5 mm

Force applied by a compressed SAF
100
150
200
250
300
350
400
450
500
0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65
Canal Diameter (mm)
SAFForce(g)

Gradual expansion by the SAF
Dr. Michael Solomonov, Israel

Circumferential 3D adaptation
* Compare this to the last rotary instrument

Mode of operation
1. Vertical vibration – 0.4 mm amplitude
at 5,000 rpm
2. Slow low-torque rotation – at ~80 rpm
3. Clutch mechanism to avoid rotation
while engaged with canal walls
4. Continuous irrigation

Repeated Motion
The gentle vertical vibration helps
achieve a gradual enlargement of the
root canal.

All these create the
“Sand Paper effect”
• Abrasive Surface
• Repeated Motion
• Light pressure
• Creation of “Dentin Dust”
• Irrigation washes the debris away

0
0.5
1
1.5
2
2.5
3
3.5
4
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Working Time (min)
EnlargementbyISO#Dentin removal by the SAF
Working time (min.)
Dentinremoval–standardizedbyISO#

Continuous Irrigation

The SAF’s hollow design allows
continuous irrigation of the root canal through its lumen
Continuous Irrigation -VATEA

Continuous Irrigation - EndoStation

Continuous simultaneous irrigation

Low-pressure irrigation

NaOCl refresh rate during irrigation

Three Standard Lengths: 21mm, 25mm, 31mm
Diameters: 1.5mm, 2.0mm

SAF - introduction

Evidence Based Endodontics

57 published peer-reviewed articles in 4Years
33 articles on
Journal of
Endodontics
8 articles on
International
Endodontic
Journal

No Micro-cracks Formation
Safety in Use

Hero Shaper
Yoldas et al, J Endod 2012; 38:232-235

ProTaper (complete fracture)

Dentinal micro-Crack Formation during Root
Canal Preparations by Different NiTi Rotary Instruments
and the Self-Adjusting File
60%
25%
40%
30%

SAF

Kim et al. J Endod 2010; 36(7):1195-9 Kim et al. J Endod 2013; 39(12):1572-5
Stress generation in the dentin –
comparison of rotary files to SAF
“SAF generated a
minimal reaction force
and resulted in minimal
dentin removal.
This could contribute to
the reduction of the
fracture risk and dentinal
defects”

No Packing of Debris
Safety in Use

SAF
1.7% debris
Paqué et al, Int Endod J 2012; 45(5):413-8
ProTaper
10.1% debris
Hard-tissue debris accumulation created by
conventional rotary versus self-adjusting file
instrumentation in mesial root canal systems of
mandibular molars
+ EDTA
1.3% debris
+ EDTA
7.9% debris

Virtually No File Separation
Safety in Use

Mechanical Failure Patterns

Chance for file separation
Dr. Guillaume Jouanny (France)
15 / 2517 (0.6%)
• 12 / 15 retrieved manually (by Hedström
or otherwise)
• 3 / 15 bypassed and obturated
Solomonov et al (manuscript submitted)

Treating C-Shaped Canals
The Challenge of C-Shaped Canals: A Comparative
Study with Self Adjusting File (SAF) and ProTaper
Michael Solomonov, Frank Paqué, Bing Fan, Louis Berman.
J Endod Feb 2012

3DView of C-shaped Canals
Solomonov et al, J Endod 2012; 38:209-214

C-Shaped canals - Danger zone
SAF ProTaper
Solomonov et al, J Endod 2012; 38:209-214 Green - before preparation Red - after preparation

C-Shaped canals - Danger zone
SAF ProTaper
Green - before preparation Red - after preparationSolomonov et al, J Endod 2012; 38:209-214

SAF
39%
ProTaper
67%
80
70
60
50
40
30
20
Percentage ofArea Unaffected by the Procedure
C-Shaped canals

Extreme oval canals
Green - before preparation Red - after preparation

Percent Untreated Root Canal Surface
µCT Analysis -Maxillary Molars
1 Paqué et al 2009
ProFile
ProTaper
Flexmaster
Lightspeed
GT
NiTiKFile
2 Peters et al 20111. Paqué et al 2009
ProFile
ProTaper
Flexmaster
Lightspeed
GT
NiTiKFile
SAF
2. Paqué et al 2011

SAF (n= 20)**
SAF 37.4% 40.1%
Paqué et al J Endod 2011;37:517–521
Percent Untreated Root Canal Surface
µCT Analysis - Distal roots of mandibular
molars
(long-oval canals)
Rotary (n= 12)*
Whole canal Apical third
Hedström 73.3% 74.7%
ProTaper - as 1 canal 79.9% 65.2%
ProTaper - as 2 canals 59.6% 65.2%

Circumferential Adaptation
Red – before preparation Blue – after preparation with SAF

“key- hole”
appearance
of
preparation
Preparation of vital extracted teeth with oval canal anatomy
De-Deus et al, J Endod 2011; 37:701-705
HistologicalAnalysis

Continuous No-pressure
Irrigation with
Activation & Scrubbing

RinsingScrubbing

The Self-adjusting File (SAF). Part 3: Removal of Debris and
Smear Layer—A Scanning Electron Microscope Study
Cleaning by the SAF, with a hybrid
irrigation technique – NaOCl and EDTA:
Coronal third: 100% free of debris
100% free of smear layer
Middle third: 100% free of debris
Apical third: 100% free of debris
Metzger et al, J Endod 2010; 36:697–702

Removal of Debris and Smear Layer
in Curved Root Canals Using Self-Adjusting File with
Different OperationTimes – A Scanning Electron Microscope Study
ApicalThird Results:
Debris removal:
SAF: 75% – 90%
Rotary: 39%
Smear layer removal:
SAF: 64% – 67%
Rotary: 25%
YİĞİT ÖZER; Int Dent Res, 2011; 1:1-6

SAF
Bio-Race
Siqueira et al, J Endod 2010; 36:1860-65
Ability of chemomechanical preparation using Rotaries vs. SAF
MicrobiologicalAnalysis

A Comparative Study of Biofilm Removal with Hand,
Rotary Nickel-Titanium, and Self-Adjusting File Instrumentation
Using a Novel InVitro Biofilm Model
Lin, Haapasalo et al, J Endod 2012; 39:658-63
SAF
3.25%
Profile
19.25%
K-file
26.98%
Percentage area inside the groove covered by bacterial biofilm after treatment:

SAF
is the first true
Chemo-mechanical
endodontic instrument !

Root canal
Obturation

DeDeus et al, J Endod 2012; 38:846–849
ProTaper 77.5%SAF 90.5%
“A significantly higher PGFA was found in oval-shaped canals
prepared using the SAF system with continuous irrigation
compared with similar canals prepared using a conventional NiTi
rotary system (ProTaper Universal) with syringe and needle
irrigation”

Box-plots of micropush-out bond strength data
DeDeus et al, J Endod 2013; 39:254–257
Self-Adjusting File Cleaning-Shaping-Irrigation System
Improves Root-filling Bond Strength

Obturation should take morphology into consideration
What is the apical size?
Dr. Amir Weissman, Israel

?
?
#40 or #110?
Obturation should take morphology into consideration
What is the apical size?

What is the apical shape?
Step 1:
Assess the canal shape
and the apical size

Shape… Dry… Fill…
Not suitable
in irregular canals
Single cone concept

Multiple master cones
Lateral compaction

Oval pluggers?
Heat-softened GP

Cold oval pluggers?
Injectable GP

Two obturators?
Obturators

• BC sealer only
• BC + BC-coated GP
• BC + Uncoated GP
• BC + C-point
Bioceramic Sealer

Customized GP
Industrial master cones =
Adapting the canal
to a given master cone
Customized master cones =
Adapting a master cone
to the individual canal

Customized GP
2-3 mm
5-6 mm

Customized GP
2 seconds15 seconds

Customized GP
#80 #110 Buccal Mesial

Buccal Mesial Buccal Mesial
2 sec.
15 sec.
Customized GP

Root canal
Re-treatment

Obturation ProTaper
35%
SAF
7%
Abramovitz et al. Int Endod J 2012; 45(4):386-92
% of unclean canals in the apical section
Effectiveness of a Self-Adjusting File to Remove
Residual Gutta-Percha after Retreatment with Rotary Files

Obturation SAF
Solomonov et al, J Endod 2012; 38:1283–1287
ProTaper
D1 - D2 - D3
+
F1, F2
(Brushing)
Remaining GP
volume: 0.4%
5 minutes
Self-Adjusting Files in Retreatment:
A High-Resolution Micro–ComputedTomography Study
Remaining GP
volume: 5.4%
10 minutes
Profile 25/0.4
+
SAF 2.0mm

Clinical Cases

Dr. Michael Solomonov DMD
Tel- Aviv, Israel

Tel- Aviv, Israel

Jan 2011 – C-shaped
Dr. Ephie Sharlin DMD
Tel- Aviv, Israel
5 months follow-up

Dr. Ajinkya Pawar DMD
Mumbai, India

Dr. Adam Zawadka DDS
Poznan, Poland

Dr. Massimo Mori DMD
Genova, Italy

Tel- Aviv, Israel

October 2011 5 months follow-up
Dr. JoAnn Lam BDS
Singapore

March 2012
Dr. JoAnn Lam BDS
Singapore

Dr. Marino Borrelli DMD
Salerno, Italy

Dr. Dmitriy Koudryashov D.M.D
Samara, Russia
Before
After

May 2012 4 months follow-upJune 2012
Dr. Shalom Arbiv DMD
Jerusalem, Israel

One year follow-up
Dr. Osnat Keisar DMD
Tel- Aviv, Israel

What did we discuss today?
Requirements of RCT Current technologies New technology

Better Shaping
3D adaptation,
Preservation of sound dentin
Better Cleaning
Simultaneous irrigation and
disinfection,
Removal of debris and smear layer
Safety in treatment
Very low chance of separation,
Avoiding “NaOCl accidents”,
Avoiding debris extrusion/packing,
No risk of micro-cracks
Better
Re-treatment
Improved removal of GP
remnants
Better Obturation
3D adaptation to the canal,
Compatible with
various techniques

SAF – Principles of operation

Clinical guidelines – main points
• Creation of reproducible glide-path:
 Coronal access
 Apical access:
• Wide Canals: over #35  SAF 2.0mm
• Easy Canals: #20-#30  SAF 1.5mm
• Moderate Canals: #15  Glidepath + SAF 1.5mm
• Difficult Canals: ≤#10  Glidepath + SAF 1.5mm
• Choose the length of the SAF according to the active part.

• Insert the SAF manually, to assure access
and examine root’s axis
• If working length is not achieved with the
SAF in 30 seconds –re-establish glide-path
• Beware of buckling of the SAF during work –
keep the root’s axis

ThankYou!

SAF System presentation - July 2014

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SAF System presentation - July 2014